With two crashes in five months of the new 737 4th Generation a design flaw seemed likely. We look at how Boeings focus on cost-avoidance, grandfathering and bending probabilities during design would ultimately cost 346 people their lives. With John Chidgey. Related episodes: Causality Episode 10: The Comet Causality Episode 14: Concorde Investigation and Reports: FAA Finds New Safety Risk in Boeing 737 Max KNKT JT610 Final Report NTSB ASR-19-01 Safety Recommendation Report JATR Report: Boeing 7...
Jan 30, 2020•1 hr 6 min
In 2000 the small township of Walkerton Ontario witnessed the largest outbreak of E.Coli infections in Canada's history. The water utility claimed the town water was safe, but it wasn't and many people paid with their lives. With John Chidgey. Links of potential interest: Walkerton Ontario Toronto Ontario Walkerton E. coli Outbreak Death On Tap: The Poisoning Of Walkerton (Google Text-only Cache) The Walkerton Inquiry Report Heavy Rainfall and Waterborne Disease Outbreaks: The Walkerton Example ...
Dec 06, 2019•34 min
The evening before Christmas Eve in 2015 saw a widespread blackout of the power grid across the Ukraine. We look at how a cyber-attack on electric utility companies in Europe, changed how cyber-security is regarded in control systems, forever. With John Chidgey. Links of potential interest: December 2015 Ukraine Power Grid Cyber-attack Analysis of the Cyber Attack on the Ukrainian Power Grid [PDF] Ukraine Report: When The Lights Went Out [PDF] Inside the Cunning, Unprecedented Hack of Ukraine’s ...
Oct 03, 2019•26 min
As part of Rio's preparations for the Olympics in 2016 a cycling pathway was built adjacent to a narrow, congested roadway along a picturesque shoreline. When a section collapsed only months before the opening ceremony killing two people, the world looked on with growing concerns about the imminent Olympics. With John Chidgey. Links of potential interest: Deaths on Collapsed Rio de Janeiro Bike Path Deal Safety Blow to Olympic Host Anger Grows Over Rio Bike Path Failure - WSJ Questions Continue ...
Jul 04, 2019•19 min
In 2009 an AirBus A320 departing LaGuardia Airport in New York suffered a dual engine failure due to a bird strike during takeoff. In a highly improbable event an equally highly improbable landing in the Hudson River shocked and amazed the world. We look at what went right on Flight 1549. With John Chidgey. Links of potential interest: US Airways Flight 1549 The Miracle On The Hudson NTSB Official Report (PDF) 49 CFR 830.2 Definitions CFM International CFM56 Chesley Sullenberger Jeff Skiles What...
Jun 04, 2019•23 min
In 1986 an unremarkable building in Singapore collapsed killing dozens of people. We look at how the supervision of the construction and the design itself resulted in a structure that was at best critically stable, and ultimately one that could only ever fail. With John Chidgey. Prior Episode References: Causality Episode 5: Maccabiah Causality Episode 15: Sampoong Department Store Links of potential interest: Hotel New World Collapse Collapse of Hotel New World Structural Load Report of the Inq...
May 09, 2019•25 min
On the 27th of June, 1988 in central Paris a runaway train collided with a stationary train in Gare De Lyon station, claiming 56 lives and injuring 60 more. Whilst the court found the driver guilty and sent him to jail, was he solely to blame? We look at how poor design decisions made Gare De Lyon inevitable. With John Chidgey. Prior Episode References: Causality Episode 6: Amagasaki Links of potential interest: Gare de Lyon Rail Accident SNCF SNCF Class Z 5300 Gare de Lyon Paris Gare de Lyon - ...
Apr 04, 2019•28 min
In December, 1984 in the city of Bhopal in central India, a Union Carbide Pesticide plant would fail and release tonnes of toxic gas into the city, killing thousands of people. It was the worst industrial disaster in human history. We follow the threads and trace back the root causes behind the incident at Bhopal. With John Chidgey. Links of potential interest: Bhopal Carbaryl Methyl isocyanate Bhopal Chronology (PDF) LABOR REPORT ON BHOPAL CITES PLANT MODIFICATION Eight convicted over India gas...
Feb 07, 2019•36 min
In 2010 an Oil Drilling Rig suffered a catastrophic well blowout, killing 11 people, destroying the rig and leading to the worst maritime oil spill in history. It all happened a few hours after the well was declared safe and ready for handover. We look at the human and financial factors that led to the incident at Macondo. With John Chidgey. Links of potential interest: Deepwater Drilling Semi-submersible Platform Macondo Prospect Macondo Prospect Gulf of Mexico Deepwater Horizon MC252 Data ERMA...
Jan 08, 2019•47 min
In 2003 the Space Shuttle Columbia launched successfully but after its mission was completed burned up on re-entry with the loss of all onboard. We look at how normalisation of deviation blinded many at NASA to a risk that had existed since 1981. With John Chidgey. Links of potential interest: Space Shuttle Columbia Space Shuttle Columbia Disaster STS-107 When The Space Shuttle Didn’t Come Home Columbia Space Shuttle Disaster Explained List of Space Shuttle Missions A New Vision for NASA STS-27 ...
Dec 13, 2018•27 min
When two trains collided head on at Kipton, Ohio in 1891, it was a wake up call for the railroad industry in North America whose impacts would be far-reaching and would lead to a new timekeeping standard that was unprecedented. With John Chidgey. Links of potential interest: US Timepiece Industry and Railroad Watch Kipton Train Wreck Anniversary The Great Kipton Train Wreck Kipton Train Crash Kipton Train Collision Railway Post Office Support Causality on Patreon Episode Gold Producer: 'r'. Epis...
Aug 31, 2018•19 min
The largest nuclear incident in human history released an estimated 400 times the radioactive material compared to Hiroshima and Nagasaki. It all happened because of a test that was delayed by one shift, or was it the ultimate inevitability of a flawed reactor design? With John Chidgey. Prior Episode References: Causality Episode 3: Fukushima Causality Episode 17: Three Mile Island Technical References: Iodine-135 Periodic Table List of Chemical Elements Xenon Poisoning in Reactors Nuclear Energ...
Jul 08, 2018•47 min
A turning point in control systems user interface design and alarm management happened in an unlikely place that few have ever heard of. We look at what went wrong at Milford Haven. With John Chidgey. Links of potential interest: The explosion and fires at the Texaco Refinery, Milford Haven Milford Haven HSE Accident Report [PDF] Alarm Management Abnormal Situation Management [PDF] Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producers: Chris Stone and Carsten Hansen....
Apr 29, 2018•32 min
On the 19th of July, 1985 in Tesero, Northern Italy, a tailings dam gave way and killed 268 people. With the most common tailings dam design in the world, what went wrong and how widespread are the risks? With John Chidgey. Links of potential interest: Stava tailings dam failure Water Management Considerations for Conventional Storage Conventional Impoundment Storage - The current techniques The Stava Mudflow of 19 July 1985 PDF Liquefaction The Val di Stava Dam Collapse Mine Tailings Safety Sta...
Feb 24, 2018•22 min
In 2015 at Alton Towers in the UK, The Smiler Rollercoaster experienced a major incident leading to severe injuries for multiple riders. We look at how pressure to get the ride running again and mis-communication defeated the system designed to protect the riders. With John Chidgey. Links of potential interest: Alton Towers The Smiler How Alton Towers Smiler Crash Unfolded Alton Towers Smiler Crash Footage Released Alton Towers Smiler Ride Reopens Support Causality on Patreon Episode Gold Produc...
Nov 22, 2017•20 min
In 1952 a fog in London left 4,000 dead in just 4 days but many more would die before the causes could be rectified. Worse than that, it had happened before and it’s happening again right now, somewhere else. With John Chidgey. Links of potential interest: Inversion (meteorology) Great Smog of London Battersea Power Station Clean Air Act 1956 Trams in London 1948 Donora Smog Pollution in China Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producers: Chris Stone and Eivi...
Sep 14, 2017•20 min
On March 28, 1979 Unit 2 of the Three Mile Island Nuclear Plant in the United States of America an incident would lead to a partial reactor core meltdown. Many blamed the operators for stopping the reactor cooling system but the real root causes showed a known flaw in the design and alarm flooding had blinded the operators to what was actually happening. With John Chidgey. Related episodes: Causality Episode 3: Fukushima Links of potential interest: Three Mile Island accident Three Mile Island N...
Jun 02, 2017•33 min
In 1977 on the small island of Tenerife two 747 Jumbo Jets collided on the runway in poor visibility. A miscommunication clearly occurred, but even today, the same elements still exist and it could happen again. With John Chidgey. Links of potential interest: Tenerife-North Airport Teide Surface Movement Radar Air Travels Communications Killer Flight Global Another 737NG PFD Question Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producers: Chris Stone, Eivind Hjertnes a...
Mar 10, 2017•29 min
The Sampoong Department Store in South Korea collapsed in 1995 killing over 500 people. The investigators were shocked to find just how many rules had been broken but the true root cause might have been something more innocuous. With John Chidgey. Links of potential interest: Failures of the Sampoong Department Store Sampoong Department Store Collapse Sampoong Superstore PDF Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producer: Chris Stone....
Jan 27, 2017•28 min
The Concorde was the first commercially successful supersonic aeroplane that flew for nearly 25 years without a fatality and was considered the safest aeroplane in the world at the time until it crashed. The incident ended the lives of 113 people and it ultimately ended the Concorde itself. With John Chidgey. Links of potential interest: Tupolev Tu-144 Concorde 40 Fascinating Facts About The Concorde The Concorde SST Accident Report The Untold Story of the Concorde Disaster Aircraft Runway Requi...
Dec 22, 2016•25 min
A near-new modern cruise liner with all the navigational aids and maps struck rocks and sank killing over 30 people and the man most responsible still walks free today. With John Chidgey. Links of potential interest: Costa Concordia Costa Concordia Disaster Costa Concordia - What Happened The Costa Concordia Sinking Costa Concordia Maritime Accident Casebook Draft (hull) Costa Concordia Captain’s Appeal Rejected Italy Court Upholds Costa Concordia Captain’s Sentence Support Causality on Patreon ...
Nov 13, 2016•25 min
The Mont Blanc tunnel cut hours off the journey between Italy and France and in 1999 in a fire emergency services were unable to save 38 lives. We look at why. With John Chidgey. Links of potential interest: Mont Blanc Tunnel Culvert NFPA - Highway Vehicle Fires The Fire Triangle Carbon Monoxide Poisoning Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producer: Chris Stone....
Sep 29, 2016•23 min
For decades Flint Michigan derived safe drinking water from Detroit. When the supply was switched to save money a series of events unfolded and their supply became undrinkable. How could this happen? With John Chidgey. Links of potential interest: Lead and Copper Rule Here’s what drinking water pipes look like with and without corrosion control Flint Corrosion Control Presentation (PDF) How Lead Ended Up In Flint’s Tap Water List of Five Basic & Immediate Needs for Physical Human Survival Ho...
Jul 03, 2016•27 min
The Comet was the worlds first commercial jet aeroplane and those that flew aboard it formed the so-called JetSet. When they started to crash, the world of aviation changed forever. With John Chidgey. Links of potential interest: de Havilland Comet ASN Aviation Safety Database Flying back to the Fifties Frank Whittle Effects of high altitude on humans Material Fatigue de Havilland BOAC Flight 781 Disaster in the Air Non-destructive Testing Applications in Commercial Aircraft Maintenance Support ...
Jun 05, 2016•24 min
The largest airship ever constructed burst into flames when trying to land in 1937 in New Jersey in what has become one of the most striking disasters of modern times. With John Chidgey. Links of potential interest: LZ 129 Hindenburg Hindenburg Disaster R101 Flash Point Hindenburg Passenger Ticket Herbert Morrison Support Causality on Patreon Episode Gold Producer: 'r'. Episode Silver Producers: Chris Stone and John Whitlow....
Apr 27, 2016•27 min
The Challenger Space Shuttle was directed to launch on the coldest day on record in Florida and 73 seconds after launch it exploded but the engineers saw it coming. With John Chidgey. Links of potential interest: The Challenger Crew Plunged to Their Deaths Moonraker - IMDb Space Shuttle Space Shuttle Challenger Space Shuttle Challenger Disaster NASA Shuttle Missions List of Space Shuttle Missions Thiokol Challenger: Twenty Years Later, Lessons Never Learned Space Ship Two Max Q The Challenger La...
Mar 10, 2016•37 min
The Piper Oil field in the North Sea became the site of one of the worst Offshore Oil Rig disasters in history when Piper Platform Alpha went up in flames. With John Chidgey. Links of potential interest: Human Factors and Ergonomics for Shift Handover Piper Alpha Natural-gas Condensate Support Causality on Patreon Episode Gold Producer: 'r'....
Feb 11, 2016•29 min
The Amagasaki rail crash was entirely caused by human error but was it a fear of punishment by the company that was ultimately the cause. With John Chidgey. Links of potential interest: Amagasaki Rail Crash Fukuchiyama Line ICAO - Annexes Booklet ICAO - Personnel Licensing FAQ JTSB Accident Report English Extract Aircraft and Railway Accidents Investigation Commission Fatigue JR West Punished Staff Support Causality on Patreon...
Jan 29, 2016•23 min
The 15th Maccabiah Games in 1997 had a temporary bridge for the opening ceremony. The world was shocked when it failed and it did so on every level. With John Chidgey. Links of potential interest: 1997 Maccabiah Games Maccabiah Games The Maccabiah Bridge Collapse Google Maps: The Site of the Disaster Australia/Israel Review: The Bridge Too Far Phil Moss Recalls the Tragic Death of Four Aussies… Maccabiah Tragedy Australian Jews blast Rehiring of Officials Responsible for the Maccabiah Tragedy St...
Dec 23, 2015•20 min
The Titanic famously sank on her maiden voyage with a huge loss of life. No ship is unsinkable. With John Chidgey. Links of potential interest: List of Ships Sunk by Icebergs Titanic Timeline Time Line Titanic: The Myth of the Unsinkable Ship Seamen’s Act RMS Titanic Titanic Facts: Statistics about The Sinking of the Ship Lifeboats of the RMS Titanic Was the Titanic Ever Publicised as Unsinkable? Why Did People Believe Titanic Was Unsinkable? Titanic Deckplans : Tank Top RMS Republic Internation...
Dec 11, 2015•24 min
